Have you ever been convicted of a: Felony? Misdemeanor? Traffic infraction (moving violation)? if yes, please explain

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1 EMPLOYMENT APPLICATION An Equal Opportunity Employer Date Position Applied for Full Time Part-Time Seasonal Temporary Date you can begin work This application must be filled out, completely in order to be considered for employment. You may provide a resume, although you must also complete this application. Please print in ink or type and do not leave any blank spaces. PERSONAL INFORMATION Name Address City State Zip Code Address Phone Number (day) (evening) (message) How long at present address? previous address? Are you over 18 years of age? Are you over 21 years of age? Are you lawfully eligible to be employed in this country? yes no (proof of citizenship or immigration status will be required upon employment) Are you a veteran? yes no Have you ever worked for Oldham County Fiscal Court in the past? if yes, when? What department? Your name when employed by Fiscal Court, if applicable Do you have any relatives working for Oldham County Fiscal Court? yes no If yes, whom? Do you have a valid drivers license? Issuing State Do you have a Commercial Driver s license? License ID# List endorsements (if any) Expiration Date Have you ever been convicted of a: Felony? Misdemeanor? Traffic infraction (moving violation)? if yes, please explain (A conviction does not automatically eliminate you from employment consideration. The nature of the offense, when it occurred and your truthfulness may be taken into consideration.) We are a drug free workplace; you will be required to have a drug test administered prior to employment. 1

2 EDUCATION Name and Address Did you graduate? Y or N Diploma/Degree completed Field(s) of study High School College: Other (i.e., military, Vocational, technical, etc.) Please list your professional memberships, certificates, designations, licenses, honors, awards, fellowships, etc U.S. MILITARY SERVICE List below any and all military service you have had or are presently serving. Branch Rank and Type of Service Training/ExperienceReceived EMPLOYMENT HISTORY (this section must be completed, it cannot be substituted with a resume) List all experience in order starting with your present or most recent position and working backwards. Account for all periods of unemployment. Attach additional sheet(s), as needed. 2

3 USE THIS SPACE FOR ANY SPECIAL QUALIFICATIONS YOU MAY HAVE RELEVANT TO THE POSITION FOR WHICH YOU ARE APPLYING. 3

4 REFERENCES NAME OCCUPATION YRS. KNOWN ADDRESS ALL APPLICANTS PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING: I understand that completion of this application does not indicate that there are any open positions and does not in any way obligate Fiscal Court to hire me or offer me a job. I understand that Oldham County Fiscal Court is an equal opportunity employer and selects individuals based upon job-related qualifications regardless of race, color, religion, sex, national origin, age or handicapped status. In the processing of my application, an investigation will/may be made whereby information is obtained from former employers and references. Permission is hereby granted to any school, person, firm, or corporation whether my former employer or otherwise, to give Oldham County Fiscal Court information that may be required to arrive at an employment decision, and I hereby release Oldham County Fiscal Court, its officers, employees, representatives, or agents from any and all liability and/or damage incurred by myself in obtaining such information I understand that employment and compensation can be terminated, with or without cause or notice at any time, at the option of either Oldham County Fiscal Court or myself, and that no manager or supervisor has the authority to enter into an employment agreement for any specified period of time or to make agreement contrary to the foregoing. I understand that Oldham County Fiscal Court reserves the right to use any method of investigation which, at its sole discretion, it deems reasonable and necessary to determine whether any employee has engaged in conduct warranting disciplinary action, including, but not limited to a search of any property of mine on Oldham County Fiscal Court premises. As a condition of continued employment, if hired, I agree to cooperate in any such investigation. I understand that if hired, my continued employment is predicated upon the truthfulness and accuracy of the statements contained herein, and that I am subject to termination if any statement in this application is false or misleading. If hired, I agree to conform to the rules and regulations of Oldham County Fiscal Court as issued from time to time and that only those rules and regulations that are then in effect apply to my continued employment with Oldham County Fiscal Court. I understand this application will remain active for six (6) months and if I have not been hired by that date, I must renew my application to be considered for future employment. Signature Date FOR OFFICE USE ONLY Interviewed by: (1) (2) (3) Starting Date Rate Classification Approved by: (1) (2) (3) 4

5 APPLICANT CONSENT FORM TO INVESTIGATE AND DISCLOSE DATA I,, hereby allow Oldham County Fiscal Court the right to contact and investigate my former and current employers, and all other pertinent parties, including, but not limited to educational institutions where I enrolled, to fully investigate my background. I understand that as part of the interview process, since I am applying for the position of, Oldham County Fiscal Court requires all applicants to disclose pertinent data concerning previous work history, police and military records, educational activities, and credit history. The purpose and procedures used in this investigation have been fully described to me and I completely understand the reasons and potential uses of such investigations. I authorize Oldham County Fiscal Court to use any and all information acquired to make decisions regarding my employment, which may be disclosed to third parties. I understand and agree that if any material facts are discovered which differ from those stated by me on my employment application, at my interview, or at any time prior to my commencing employment at Oldham County Fiscal Court (if I am offered a position with Oldham County Fiscal Court), I will not be offered the job. Furthermore, I understand and agree that if material facts are later discovered which are inconsistent with or differ from facts I furnished before taking the job, I will be disciplined, including immediate discharge without warning. The cost of this investigation will be paid by Oldham County Fiscal Court. Nonetheless, I hereby indemnify, release and forever discharge and hold Oldham County Fiscal Court and its subsidiaries and affiliated companies, agents and employees, as well as all third parties supplying such information, harmless from any and all claims, demands, judgments and legal fees arising out of or in connection with this investigation, the results, or any lawful use of the results or disclosure thereto. Signature of Applicant Printed Name of Applicant Date: Name of Witness: 5